A patient-initiated DMARD self-monitoring service for people with rheumatoid or psoriatic arthritis: a cost-effectiveness analysis.

Hayley Mcbain,Michael Shipley,Chris Flood,Stanton Newman,Samantha Moore,Abigail Olaleye

doi:10.1093/rheumatology/keaa309

Abstract

To determine whether a patient-initiated DMARD self-monitoring service for people on MTX is a cost-effective model of care for patients with RA or PsA. An economic evaluation was undertaken alongside a randomized controlled trial involving 100 patients. Outcome measures were quality of life and ESR assessed at baseline and post-intervention. Costs were calculated for healthcare usage using a United Kingdom National Health Service economic perspective. Sensitivity analysis was performed to explore the impact of nurse-led telephone helplines. Uncertainty around the cost-effectiveness ratios was estimated by bootstrapping and analysing the cost-effectiveness planes. Fifty-two patients received the intervention and 48 usual care. The difference in mean cost per case indicated that the intervention was £263 more expensive (P < 0.001; 95% CI: £149.14, £375.86) when the helpline costs were accounted for and £94 cheaper (P = 0.08; 95% CI: -£199.26, £10.41) when these costs were absorbed by the usual service. There were, however, statistically significant savings for the patient (P = 0.02; 95% CI: -£28.98, £3.00). When costs and effectiveness measures of ESR and quality of life measured, using the Short Form-12v1, were combined this did not show the patient-initiated service to be cost-effective at a statistically significant level. This patient-initiated service led to reductions in primary and secondary healthcare services that translated into reduced costs, in comparison with usual care, but were not cost-effective. Further work is needed to establish how nurse-led telephone triage services are integrated into rheumatology services and the associated costs of setting up and delivering them. ClinicalTrials.gov, http://clinicaltrials.gov, ISRCTN21613721.

Highlights

The increasing complexity of drug treatments and more intensive monitoring regimes have, in part, led to a huge growth in the numbers of patients with arthritis in follow-up clinics.[1]
Study design An economic evaluation was undertaken alongside a two-arm, single centre, randomised controlled trial (RCT) comparing a patient-initiated DMARD self-monitoring service with usual care
The primary findings of the RCT indicated that this alternative model of care led to reductions in the use of primary and secondary care services, and was not inferior to standard practices in regard to disease activity, pain, fatigue, quality of life or mood.[21]

Summary

Introduction

The increasing complexity of drug treatments and more intensive monitoring regimes have, in part, led to a huge growth in the numbers of patients with arthritis in follow-up clinics.[1]. In the UK[4] two-thirds of healthcare trusts were unable to offer rheumatoid arthritis patients a timely follow-up appointment. Even when these appointments do occur, 30% lead to no investigation or other actions, 35% are seen to be problem free by rheumatologists and 42% completely unnecessary.[5] As a result, the focus is on reducing unnecessary outpatient and follow-up appointments altogether, rather than redirecting care.[6]

Methods

Results

Conclusion